State Fiscal Year 2020 Safe From the Start Annual Report: 2001-2020

Introduction

The goal of the Safe From the Start (SFS) program is to identify, assess, and provide services to young children 0-5 years old, and to their siblings and caregivers, who have been exposed to violence in their home and/or community. SFS was the result of a national summit, Safe From the Start: The National Summit on Children Exposed to Violence, held in 1999 in Washington, D.C., by the U.S. Department of Justice and U.S. Department of Health and Human Services. In response, the Illinois Attorney General held an SFS Summit in 2000 to respond to the issue of young children exposed to violence in Illinois. From this summit, a working group emerged and recommended selecting demonstration sites to develop, implement, and evaluate comprehensive community models to help young children affected by violence.

The Illinois Criminal Justice Information Authority (ICJIA) assumed statewide SFS program administration from the Illinois Violence Prevention Authority in 2013 and currently supports nine sites with grant funding. Of the nine sites supported by ICJIA, six were located in Cook County (sites 2, 6, 7, 8, 9, & 12), two were in Central Illinois (sites 1 & 10), and one was in Northern Illinois (site 5). Sites 3, 4, and 11 were no longer operating after 2017, so data from these sites were excluded from this report.

Services offered to children and caregivers commonly involved therapies focused on improving child-parent communication skills and addressing the impacts of domestic violence. Children were specifically taught to identify and express their feelings and ways to cope with their symptoms, while caregivers were taught about the effects of childhood exposure to violence (CEV) and child development.

The objectives of the evaluation were to:

• identify the characteristics and experiences of young children exposed to violence and their caregivers.
• identify the types of violence that children are exposed to.
• assess the impact of violence on young children.
• identify risk factors for children at the individual, family, and community level.
• document the identification and referral process for children exposed to violence.
• document the types of services children and their caregivers received.
• assess the impact of service provision for young children and their caregivers.

This evaluation report describes the assessment and service provision activities for 4,823 children predominantly ages 0 to 5, along with their siblings and caregivers, who were exposed to violence and sought treatment at one of nine Illinois Safe From the Start (SFS) program sites between July 2001 and June 2020.

Data Collection

Data from child and caregiver assessments were collected by each site and compiled into a comprehensive database. The instruments used by SFS service providers to collect assessment and service provision data included the following:

• Background Information Form (BIF). The BIF was developed by the SFS Advisory Committee to gather demographic and background information on participating children and their families. The BIF helps tailor service provision to the individual needs and circumstances of children and their caregivers.
• Ages and Stages Questionnaire (ASQ) provides early and accurate identification of infants and young children who are at risk for developmental delays or disorders and, therefore, may need early intervention services.^[1] In the questionnaire, 30 items on child behaviors address five key developmental areas: communication, gross motor, fine motor, problem solving, and personal-social skills. Caregivers are asked to complete an age-appropriate ASQ.
• Ages and Stages Questionnaire: Social-Emotional (ASQ) provides early and accurate identification of infants and young children who are at risk of having emotional and social disorders. ^[2] Items on the questionnaire address seven behavioral areas: self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people. The ASQ:SE is completed by caregivers.
• Child Behavior Checklist (CBCL) is a valid and reliable measure of emotional and behavioral problems for young children. ^[3] The CBCL version for children ages 1½ to 5 generates a Total Problem score obtained from parents’ ratings of 99 problem items, plus their descriptions of problems, disabilities, what concerns them most about their child, and their child’s biggest strengths. The CBCL is comprised of seven syndrome scales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, Aggressive Behavior, and Sleep Problems. Derived from a combination of these scales, the CBCL can also be scored based on two broad groupings of syndromes: Internalizing and Externalizing. The grouping called internalizing refers to the set of problems experienced within the self (e.g., anxiety, withdrawn), whereas externalizing consists of problems related to conflict with other people (e.g., aggression).
• Safe From the Start Questionnaire (SFSQ) was originally developed for the Chicago Safe Start project and was designed to measure caregivers’ knowledge of the effects of exposure to violence and perceptions of their ability to care for their children and themselves following exposure to violence. The SFSQ uses a Likert Scale where caregivers indicate if they strongly disagree (1), disagree (2), are not sure (3), agree (4), or strongly agree (5) to 17 statements. Higher scores reflect greater knowledge about the impact of violence on children and greater ability to care for oneself and one’s child following exposure to violence.
• Parenting Stress Index (PSI) is a valid and reliable measure of the level of stress that caregivers experience in three areas (i.e., Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child) and provides a Total Stress score, which is a measure of the overall level of parental stress. ^[4]
• Child and Caregiver Completion of Services Forms (CSFs) were developed by service providers from all the SFS sites in 2004. This form was completed by service providers after a child or caregiver completed their treatment plan or were no longer receiving SFS services. The forms are used to describe the services that were provided to families and the outcomes of those services from the providers’ perspectives.

Data from all sites were compiled into a comprehensive database. SFS clinicians proctored the BIF, CBCL, PSI, ASQ, ASQ:SE, and SFSQ to caregivers at intake (Time 1 [T1]; pre-intervention). After five to eight sessions (Time 2 [T2]; post-intervention), only the CBCL and PSI were required to be repeated, while repeating the ASQ, ASQ:SE, and SFSQ were optional at the clinicians’ discretion. Further, the Child and Caregiver CSFs were completed upon families’ exit from services (typically after 12-16 sessions).

Findings

Sample Demographics

Since 2001, the nine SFS sites altogether assessed 4,823 children total using the BIF. Children (anyone under 18) were an average of 4.9 years old. Of all children served, 70% were between the ages of 0 and 5 years old. Collectively, more male (53%) than female children received services across sites. Racial and ethnic identities served included White (35%), Black (27%), Hispanic (24%), Multi-racial (11%), Asian (< 1%), and Other (2% e.g., American Native).

Children’s Home Environment

At intake, children primarily lived with their mothers (43%), their mothers and another relative (18%), both parents (14%), or their grandparents (6%). Mothers on average were younger (30 years) than fathers (33 years). Many families rented (47%) or owned their homes (27%), while others lived with family members (10%), in shelters (8%), or in public housing (5%). Less than 1% indicated that they were homeless. More than half of families (52%) had household incomes of less than $15,000.

Violence Exposure and Risk Factors at Intake

Violence Exposure

Data from the BIF indicated that of the children who have experienced violence, most of them witnessed domestic violence (81%). Additionally, children were victims of child abuse (15%), sexual abuse (8%), and community violence (5%). Only 2% were witnesses of community violence and 14% were exposed to other types of violence, such as neglect and witnessing the sexual abuse of a sibling (Table 1).

Table 1

Children’s Violence Exposure at Intake, by Site and Type (n = 3,502) ^[5]

Furthermore, many children referred to services were exposed to multiple types of violence. Approximately 44% of caregivers at intake reported that their children had been exposed to two or more types of violence.

Children’s Presenting Problems

Across all types of violence exposure, the most common presenting problems described by caregivers were clinging behavior, aggression toward siblings and parents, and sleep difficulties. However, children who were victims of different types of violence presented some symptoms more than others. For example, victims of child abuse were more likely to have problems with anxiety (46%), destructive behavior targeted toward property (35%), self-abusive behavior (21%), and to have visible injuries (15%) than children with other types of violence exposure. Victims of sexual abuse had higher rates of regressive behavior (e.g., loss of language, bedwetting, difficulty sleeping; 36%), somatic complaints (30%), depression (29%), withdrawn behavior (28%), and sexualized behavior (22%) compared to children exposed to other types of violence. Those children who witnessed community violence were more likely to present fearfulness (43%) and school behavioral problems (37%) than other child victims.

Risk Factors

Caregivers were asked to indicate whether their children had been exposed to 22 risk factors. Researchers ^[6] found that persons who had experienced four or more adverse childhood experiences had a 4- to 12-fold increase in health risks for alcoholism, drug abuse, depression, and suicide compared to those who had experienced none. ^[6:1] Findings show that a child having a single parent (72%), the mother having an unplanned pregnancy (62%), living in poverty (49%), and having a father in jail (49%) were among the most commonly reported risk factors. Across all sites, children had been exposed to an average of 5.2 risk factors.

Ages & Stages Questionnaire & Ages & Stages Questionnaire: Social-Emotional

Of the 2,004 children for whom ASQ pre-intervention data were available, 20% were identified at intake as at risk for developmental delays. A total of 12% of the children displayed characteristics of being at risk in a single developmental area, 7% demonstrated being at risk in two to three developmental domains, and 2% demonstrated they were at risk in four or five domains. ASQ results indicated that children at risk showed developmental delays mostly in communication skills and fine motor abilities. Pre-intervention ASQ:SE data were available for 1,784 children, and concerns about social-emotional delays were identified for 696 children (39%).

As seen in Table 2, children at most sites experienced a decrease in behaviors indicative of social-emotional delays after receiving services. Of the 570 children for whom both pre- and post-intervention ASQ:SE scores were available, 45% of children exhibited social-emotional concerns prior to receiving services. However, 26% of children at risk for social-emotional disorders pre-intervention were no longer at-risk post-intervention.

Table 2

Children with Social-Emotional Concerns at Intake, by Site and Intervention Point (n = 1,784)

Child Behavior Checklist

Baseline results show that of the 2,408 children across sites for whom CBCL data was available, between 5% and 17% of children scored in the borderline range and between 7% and 29% scored in the clinical range for behavior problems at intake. Overall, 41% of children had Total Problems scores in borderline or clinical ranges at intake. The percentage of children with post-intervention Total Problems Scores in the borderline or clinical ranges decreased from 41% pre-intervention to 25% post-intervention (Table 3). Anxiety/depression, aggressive behavior, and sleep problems decreased the most following services.

Table 3

Children with CBCL Total Problems Scores in CBCL Borderline or Clinical Ranges, by CBCL Scales and Intervention Point (n = 1,021)

Safe From the Start Questionnaire

Service providers collected SFSQ data from 2,149 caregivers pre-intervention and 900 caregivers post-intervention. Statistical analysis of the matched pre- and post-intervention SFSQ data indicated improvement in overall scores from Time 1 to Time 2 [t(899) = 9.3, p < .001] (Table 4). Examination of the subscales revealed that scores on caregivers’ knowledge of Childhood Exposure to Violence (CEV) changed the least, while scores improved the most in the areas of self-care and ability to help their children upon CEV. Pre-intervention SFSQ average scores showed caregivers already had substantial knowledge of the effects of exposure to violence prior to receiving services.

Table 4

Caregivers’ Matched SFSQ Scores, by Intervention Point (n = 900)

Parenting Stress Index

At baseline, 43% of caregivers assessed had a total PSI score at or above the borderline range (85th-89th percentile), and 35% had a total stress index score in the clinical range (at or above the 90th percentile). In other words, majority of caregivers reported experiencing significant levels of parental stress when starting services. For the 1,662 caregivers for whom Time 1 and Time 2 PSI data were available, 42% had Total Stress scores in the borderline range at Time 1, whereas 32% had Total Stress scores in the borderline range at Time 2 (Table 5). Overall, 24% fewer caregivers fell in the borderline range following services [t(1661) = 8.6, p < .001]. Scores for Parental Distress showed the greatest improvement between Time 1 and Time 2 with a 29% change [t(1708) = 8.6, p < .001]. This data suggests that services were effective at relieving parental distress.

Table 5

Caregivers with PSI Scores at or Above PSI Borderline Range, by PSI Subscale and Intervention Point

Completion of Services Forms

After services to a family were completed, providers completed a Professional Summary Report (PSR), a scale contained within the CSF. Staff at each site rated each children’s improvements in 15 areas of functioning and each caregiver on 10 areas on functioning on a scale of 1 to 4, with 1 indicating that the area of functioning declined over the course of services, 2 indicating no change, 3 indicating improvement, and 4 indicating that the child or caregiver greatly improved in that area of functioning. Results for children indicate that service providers rated “Child’s ability to identify feelings,” “Overall symptoms,” and “Child’s PTSD-Intrusion” as most improved, while “Child’s functioning at school,” “Child’s impulse control,” and “Child’s ability to return to a school/childcare setting” were rated least improved. Results for caregivers show that service providers rated “Caregiver’s knowledge of the impact of traumatic events” as most improved, and “Caregiver’s having supportive relationships” was rated least improved.

Number of Sessions

Simple correlations between the number of sessions and outcomes as measured by the PSR reveals that the more sessions children attended, the more children improved following services (r = .25, p < .001) (Figure 1). Similarly, the more sessions caregivers attended, the more caregivers improved (r = .21, p < .001).

Figure 1

Mean PSR Scores, by Number of Sessions and Client Type

Figure 1 also shows that of children with completed PSRs (i.e., less than two missing values on the PSR) and a recorded session number (n = 2,429), children who terminated services prior to one or two sessions experienced little or no change in outcomes. After three sessions, PSR scores generally improved with more sessions. Of caregivers with completed PSRs and a recorded session number (n = 1,685), results showed a similar pattern of improvement in PSR scores, with outcomes improving as the number of sessions increased. Improvements in outcomes were generally observed after six sessions for caregivers.

Additional Exposure to Violence & Service Referrals

Following services, staff indicated whether families were exposed to additional violence after services began. Out of 2,765 children, 19% were exposed to additional violence after services began. Staff also indicated that 14% of 1,920 caregivers were exposed to additional violence while participating in services.

Service providers not only directly served families exposed to violence, but also provided 1,793 internal and external referrals in the last 19 years to address additional victim needs. Clients were most often referred for counseling, childcare, domestic violence services, food/clothing, educational and legal advocacy, and transportation. A total of 239 “other” referrals were provided to SFS families such as parenting support groups, crisis nursery services, and Christmas Adopt-a-Family programs.

Conclusion

Following services, improvements were indicated across all assessment scores post-intervention. Analysis of pre- and post-intervention data showed 26% (ASQ:SE) to 39% (CBCL) fewer children scored in the borderline or clinical ranges after receiving services. Twenty-four percent of caregivers had reduced stress, according to their PSI scores. Overall, providers identified improvements in child and caregiver functioning. Children’s ability to identify feelings and caregiver’s knowledge of the impact of CEV greatly improved. Although Safe From the Start has proven to positively impact families exposed to violence in Illinois for almost 20 years, there are numerous challenges and opportunities for growth.

COVID-19 Impact and Additional Challenges

The COVID-19 pandemic exacerbated issues that many non-profit and community-based organizations already face. For example, low client retention has created challenges for SFS program implementation. Also, as telehealth was more widely used to provide therapy and case management, it has become more difficult for service providers to engage and keep families in services. In a 2021 needs assessment conducted by the SFS evaluators, service providers explained the reasons for such difficulties. These included diminishment of organic connection between providers and families, safety concerns on behalf of families, and a lack of online resources and technical capacities. Although some sites are transitioning back to in-person services, client retention and engagement should continue to be a priority in ongoing discussions between the evaluation team and sites.

Timely and complete data entry into the Safe From the Start database also has been an ongoing challenge at many sites. Data collection challenges have come at every step of the process, including gathering complete data from caregivers (especially from families with multiple children in the program or who unexpectedly leave services) and difficulties gathering data on children whose primary caregivers changed throughout their program participation.

Several recommendations have been suggested to improve the completeness of the data, including offering training and technical assistance opportunities to SFS sites along with encouraging ongoing, bi-directional conversations with administrative staff and providers. This will ensure that providers are consistently updated and informed about changes to evaluation processes that may impact how they deliver services to families.

Successes

One of the main successes of the SFS program has been the resiliency of sites to withstand major obstacles at the state and national level, such as the two-year Illinois budget impasse and the COVID-19 pandemic. Illinois’ SFS program has served as a national model for addressing impacts related to young children’s exposure to violence. The data indicate that among families who participated in the SFS program there were significant reductions in children’s symptoms and caregiver stress and an improvement in child and caregiver functioning. These data provide an important picture of the population receiving SFS services, the impact of exposure to violence on children, and the benefits of those services.